Prognostic indicators in peritoneal carcinomatosis from gastrointestinal cancer

Abstract

Peritoneal carcinomatosis from gastrointestinal cancer has new treatment options for surgical management. The approach uses cytoreductive surgery which combines peritonectomy and visceral resection in an effort to remove all visible cancer within the abdomen and pelvis. Then the peritoneal cavity is flooded with chemotherapy solution in an attempt to eradicate residual disease. In order to select patients for this approach the quantitative prognostic indicators for carcinomatosis were reviewed, compared and contrasted. Prognostic indicators to be used to select patients for this aggressive approach at the initiation of surgery and after completion of cytoreduction were studied. Four quantitative assessments to be used at the time of abdominal exploration were the Gilly staging, Japanese gastric cancer P score, peritoneal cancer index (PCI), and the simplified peritoneal cancer index (SPCI). All have value with the PCI being the most validated and most precise. Preoperative assessments include the tumor histopathology and the prior surgical score. The completeness of cytoreduction score is an assessment of residual disease after a maximal surgical effort. An opportunity for long-term survival following treatment for carcinomatosis requires a complete cytoreduction in all reports for gastrointestinal cancer. Quantitative prognostic indicators need to be knowledgeably employed when patients with carcinomatosis are being treated. Improved patient selection with greater benefit and reduced morbidity and mortality should result.

Figure 1

Right colon, terminal ileum and mucocele of the appendix. This appendix is greatly dilated; the end has ruptured releasing mucus and adenomatous epithelial cells into the free peritoneal cavity.

Figure 2

Histopathology of disseminated peritoneal adenomucinosis (DPAM). (H+E × 200)

Figure 3

Histopathology of peritoneal mucinous adenomucinosis (PMCA). (H+E × 700)

Figure 4

Histopathology of hybrid type mucinous appendiceal malignancy. (H+E × 100)

Figure 5

Peritoneal cancer index (PCI). Two transverse planes and two sagittal planes divide the abdomen into 9 regions. The upper transverse plane is located at the lowest aspect of the costal margin and the lower transverse plane is placed at the anterior superior iliac spine. The sagittal planes divide the abdomen into three equal sectors. The lines define the nine regions which are numbered in a clockwise direction with 0 at the umbilicus and 1 defining the space beneath the right hemidiaphragm. Regions 9–12 divide the small bowel. Lesion size score is determined after complete lysis of all adhesions and the complete inspection of all parietal and visceral peritoneal surfaces. It refers to the greatest diameter of tumor implants that are distributed on the peritoneal surfaces. Primary tumors or localized recurrences at the primary site that can be removed definitively are excluded from the lesion size assessment. If there is confluence of disease matting abdominal or pelvic structures together, this is automatically scored as L-3 even if it is a thin confluence of cancerous implants.

Figure 6

Peritoneal carcinomatosis from colon malignancy survival by peritoneal cancer index. (Modified from Reference 13)

Figure 7

Peritoneal carcinomatosis from colon malignancy survival by cytoreduction. (Modified from Reference 13)